The present study analyzed the efficacy evaluation indexes of the randomized controlled trials(RCTs) of Chinese medi-cine in the treatment of rheumatic heart disease to lay the foundation for the construction of the corresponding core outcome index set. Clinical RCTs with a definite diagnosis of rheumatic heart disease were retrieved from CNKI, Wanfang, VIP, Sino Med, Pub Med, EMbase, and Cochrane Library from January 1, 2010, to December 31, 2020. Thirty-five RCTs were included, involving 3 314 patients and 41 efficacy evaluation indexes, which covered seven domains [traditional Chinese medicine(TCM) symptoms/syndromes, symp-toms/signs, physical and chemical examination, quality of life, long-term prognosis, economic evaluation, and safety events]. Physi-cal and chemical examination(56. 91%) and symptoms/signs(29. 27%) were the more frequently applied. The number of indexes used in a single trial ranged from 1 to 15, with an average of 4. The measurement time points of the top five indexes in the frequency of use were as follows: total response rate was reported at five measurement time points, ranging from 14 days to 6 months; left ventri-cular ejection fraction was measured at eight time points ranging from 5 days to 6 months; left ventricular end systolic diameter was measured at six time points, ranging from 5 days to 6 months; interleukin-2(IL-2) and tumor necrosis factor-α(TNF-α) were repor-ted 28 days after treatment. At present, there are many problems in the efficacy outcome indexes of RCTs in the treatment of rheumatic heart disease with TCM, such as large difference in quantity, unclear primary and secondary indexes, unreasonable selection of " surro-gate indexes", insufficient attention to long-term prognostic indexes and safety event indexes, non-standard application of composite in-dexes, long measurement period, and lack of TCM characteristics. It is urgent to establish the core outcome set for TCM treatment of rheumatic heart disease.
Drugs, Chinese Herbal/therapeutic use* ; Humans ; Medicine, Chinese Traditional ; Quality of Life ; Randomized Controlled Trials as Topic ; Rheumatic Heart Disease/drug therapy* ; Treatment Outcome

PURPOSE

The combined mitral stenosis (MS) and aortic regurgitation (AR) impose opposite loading conditions on the left ventricle. Physiologically, the relief of MS may increase the severity of AR.

METHODS

Participants were Filipinos 19 years or older, admitted because of severe MS with mild to moderate AR. The outcome of percutaneous transmitral commissurotomy (PTMC) was divided into two groups: (1) significant AR that included the increase in severity of AR: mild to moderate/severe or moderate to severe AR, and (2) the insignificant AR group, which included any decrease in the severity of AR: moderate to mild or persistence of mild or moderate AR. These groups were compared from baseline, 24 hours, 1 month, and 6 months using the same echocardiographic parameters. The numerical data between significant and insignificant tricuspid regurgitation were compared using nonparametric Mann-Whitney U test and categorical data using the χ2 test.

RESULTS

A total of 43 participants were analyzed. At 24 hours post-PTMC, the significant AR group had significantly lower left ventricular end-diastolic dimension (3.83 vs 4.5, P = 0.008), left ventricular end-systolic dimension (2.33 vs 2.97, P = 0.017), right ventricular fraction area change (38.6 vs 48.7, P = 0.025), and left ventricular outflow tract (1.66 vs 2.02, P = 0.020) and higher systolic pulmonary arterial pressure (57 vs 32.4, P = 0.008). At 1 and 6 months, there were no significant differences in echocardiographic parameters between the significant and insignificant AR groups' left ventricular end-diastolic dimension (4.58 vs 4.5, 4.64 vs 4.57), left ventricular end-systolic dimension (3.1 vs 2.9, 2.9 vs 2.91), and systolic pulmonary arterial pressure (28 vs 34.7, 33.8 vs 32.4). Those with significant AR had a higher mean Wilkin score (mean, 10; P = 0.007) and subvalvular thickening (mean, 2.6; P = 0.005).

CONCLUSION

On short-term follow-up, the presence of mild to moderate AR before PTMC does not lead to severe AR. The outcomes regardless of the group showed a good functional class and no significant echocardiographic differences when compared.

Rheumatic Heart Disease ; Mitral Valve Stenosis

PURPOSE: The gap in evidence in the management of multivalvular lesions can be addressed by providing more data on clinical and echocardiographic outcomes after percutaneous transmitral commissurotomy (PTMC) in patients with concomitant significant tricuspid regurgitation (TR) at baseline. METHODS This is a single-center cohort study of adult Filipinos 19 years or older, admitted between January 2019 and October 2020 due to severe mitral stenosis with moderate to severe TR subjected to PTMC. The outcome post-PTMC was divided into 2 groups: significant TR, which included the progression of moderate to severe TR or persistence of severe TR, and insignificant TR group, which included those with mild TR, regression of moderate to mild TR, severe to moderate, or persistence of moderate TR. The clinical and echocardiographic parameters of these groups were compared at baseline, at 24 hours, 1 month, and 6 months postprocedure. The numerical data between significant and nonsignificant TR were compared using nonparametric Mann–Whitney U test and categorical data using the x2 test.
Rheumatic Heart Disease ; Mitral Valve Stenosis ; Tricuspid Valve Insufficiency ; tricuspid regurgitation

Introduction: Coronary artery fistula (CAF) is a connection between one or more of the coronary arteries and a cardiac chamber or great vessel. This is a rare defect and occurs in only 0.2% of the population. Most of the cases are congenital but acquired causes are also reported. A CAF may occur as an isolated cardiac defect or with other cardiac diseases such as rheumatic heart disease (RHD). Only a few cases of coexisting CAF and RHD have been reported. Local data reports only 0.69% CAFs associated with congenital malformations of the heart. Only 61 patients among all patients who underwent coronary arteriography in 34 years were reported to have a CAFs. We report a case of severe mitral stenosis (MS) with a double CAF from the left circumflex (LCx) artery draining into the left atrium. Case: A 46-year old female with RHD with severe MS came in due to progressive dyspnea. The coronary angiogram revealed two fistulous tracts originating from the LCx draining into the left atrium. She underwent mitral valve replacement (MVR) surgery, left atrial plication, and closure of the fistula drainage the left atrium. The postoperative course was uneventful. Discussion A CAF is often asymptomatic until the second decade of life. Untreated, this may progress and cause ischemic and heart failure signs and symptoms. The presence of MS caused elevated left atrial pressure which might have prevented the increase in the volume of blood draining from the LCx artery to the left atrium through the fistulas. Hence, the MS might have prevented the dilatation of the two fistulas. Surgical correction is also indicated in the fistulas since resolution of the mitral stenosis with MVR will decrease the LA pressure which might result to dilatation and increased drainage of the fistulas causing complications later.
Rheumatic Heart Disease

Atrial fibrillation (AF), the most common chronic arrhythmia in adults, is rarely reported in children. Moreover, most of the previously reported children with AF have comorbidities, such as structural heart diseases, rheumatic diseases, and thyroid diseases. This case report is about a healthy 9-year-old boy who was diagnosed with AF without cardiac anomaly. He visited the emergency department with chest pain and palpitation, lasting 2 hours. His electrocardiogram showed narrow-complex tachycardia, which led to the diagnosis of supraventricular tachycardia. The administration of adenosine revealed rapid irregular P waves. After electrical cardioversion, cardiac rhythm was converted to normal sinus rhythm. This case report suggests that when children with narrow-complex tachycardia visit the emergency department, the possibility of AF, in addition to supraventricular tachycardia, should be considered if the RR intervals are markedly irregular.
Adenosine ; Adult ; Arrhythmias, Cardiac ; Atrial Fibrillation ; Cardiovascular Diseases ; Chest Pain ; Child ; Comorbidity ; Diagnosis ; Electric Countershock ; Electrocardiography ; Emergency Service, Hospital ; Humans ; Male ; Pediatrics ; Rheumatic Heart Disease ; Tachycardia ; Tachycardia, Supraventricular ; Thyroid Diseases

BACKGROUND: Rheumatic fever (RF) and Rheumatic heart disease (RHD) patients Rheumatic Heart Disease (RHD) patients necessitate secondary prophylaxis with benzathine penicillin G (BPG) injection every 3 weeks to prevent recurrences and complications. Patients with rheumatic fever on regular benzathine penicillin G injection usually experience moderate to severe pain resulting to poor compliance to treatment. 

OBJECTIVES: This study aims to compare the effect of BPG diluted in lidocaine hydrochloride 1%  versus diluted water in reducing injection pain in patients with RF and RHD.

METHODS: This is a randomized double-blind crossover study conducted at the PCMC OPD. Thirty-three patients diagnosed with RF and RHD were divided into 2 groups; the first group received BPG diluted in sterile water followed by BPG diluted in lidocaine hydrochloride  1% after 21 days, the second group received the same medication in reverse order. Pain scale was measured using Universal pain assessment tool immediately after injection. Paired T test was used to compare the pain score results of the two groups.

RESULTS: Pain score was significantly less in patients who received BPG diluted in lidocaine hydrochloride 1%; from an average pain score of 4.88 to 0.63 (p<0.0001), among those who received BPG diluted in sterile water. No adverse effects were seen in all patients.

CONCLUSION: This study concluded that BPG diluted in lidocaine hydrochloride 1% significantly and safely reduced post-injection pain. In all patients diagnosed with RF and RHD, BPG injection should be diluted in lidocaine hydrochloride 1% to decrease injection pain and improve patient's compliance.

Human ; Rheumatic Fever ; Rheumatic Heart Disease ; Penicillin G Benzathine ; Lidocaine ; Penicillins ; Pain

Group A Streptococcus (GAS) infections cause substantial worldwide morbidity and mortality, mostly associated with suppurative complications such as pharyngitis, impetigo, and non-suppurative immune syndromes such as acute rheumatic fever, rheumatic heart disease, and acute post-streptococcal glomerulonephritis. Deaths occur mostly in children, adolescents, and young adults in particular pregnant women in low- and middle-income countries. GAS strains are highly variable, and a GAS vaccine would need to overcome the issue of multiple strains. Several approaches have been used multivalent vaccines using N-terminal polypeptides of different M protein; conserved M protein vaccines with antigens from the conserved C-repeat portion of the M protein; incorporation selected T- and B-cell epitopes from the C-repeat region in a synthetic polypeptide or shorter single minimal B-cell epitopes from this same region; and non-M protein approaches utilizing highly conserved motives of streptococcal C5a peptidase, GAS carbohydrate and streptococcal fibronectin-binding proteins. A GAS vaccine represents urgent need for this neglected disease and should therefore deserve the greatest attention of international organizations, donors, and vaccine manufacturers.
Adolescent ; Child ; Epitopes, B-Lymphocyte ; Female ; Glomerulonephritis ; Humans ; Impetigo ; Mortality ; Neglected Diseases ; Peptides ; Pharyngitis ; Pregnant Women ; Public Health* ; Rheumatic Fever ; Rheumatic Heart Disease ; Streptococcus* ; Tissue Donors ; Vaccines ; Young Adult

A total of 39 titles related to rheumatic fever or rheumatic heart disease in Malaysia were found with online literature search dating back to their inceptions and through 2014. Additional publications from conference journals were included. Nine papers were selected based on clinical relevance and future research implications. There were no population-based studies on the incidence or prevalence of ARF or RHD. In the 1980s, the incidence of admission due to ARF ranged from 2 to 21.1 per 100 000 paediatric admission per year. The burden of disease was significant in the adult population; 74.5% of patients with RHD were female, of which 77.1% were in the reproductive age group of 15-45 years old. Rheumatic mitral valve disease constituted almost half (46.7%) of all mitral valve repairs, ranging from 44.8 – 55.8 patients per year from 1997 – 2003. From 2010-2012, mitral valve interventions increased to 184 per year, of which 85.7% were mitral valve repair. In children with ARF, 25.4% - 41.7% had past history of rheumatic fever or RHD. In patients with rheumatic mitral valve disease undergoing surgical or medical interventions, only 6% reported history of ARF, none had history of GABHS pharyngitis or antibiotic prophylaxis. Only 44.7% of patients with RHD on follow-up were on intramuscular benzathine penicillin prophylaxis. Overall, there is scarcity of publications on ARF and RHD in Malaysia. Priority areas for research include determination of the incidence and prevalence of ARF and RHD, identification of high-risk populations, evaluation on the implementation and adherence of secondary preventive measures, identification of subclinical RHD especially amongst the high-risk population, and a surveillance system to monitor and evaluate preventive measures, disease progression and outcomes.
Rheumatic Fever ; Rheumatic Heart Disease

OBJECTIVE: To summarize the outcome of tricuspid valve replacement.
 METHODS: A total of 28 patients (15 males and 13 females) underwent tricuspid valve replacement from March 2000 to February 2015 in the First Affiliated Hospital of Zhengzhou University were recruited. Among them, 16 patients were Ebstein's anomaly, 7 had rheumatic valve heart disease, 3 and 2 suffered from infective endocarditis and degenerative tricuspid lesions, respectively.
 RESULTS: One patient died of multiple organ failure. Four patients were implanted permanent cardiac pacemaker because of third degree atrioventricular block occurring in the 5th day (2 patients) and in the 9th day (2 patients) after the operation, respectively. Twenty-seven patients were followed up from 1 month to 15 years. The prosthetic valves and permanent pacemakers worked well.
 CONCLUSION Third degree of atrioventricular block, mostly appearing in early postoperative period, is the most common and severe complication of tricuspid valve replacement. The key point for prevention of damage is to accurately identify the anatomical relationship among the tricuspid valve, atrioventricular node, and conduction bundle.
Ebstein Anomaly ; surgery ; Female ; Heart Valve Diseases ; surgery ; Heart Valve Prosthesis ; Heart Valve Prosthesis Implantation ; Humans ; Male ; Pacemaker, Artificial ; Rheumatic Heart Disease ; surgery ; Tricuspid Valve ; pathology ; surgery

BACKGROUNDTricuspid regurgitation (TR) is frequently associated with severe mitral stenosis (MS), the importance of significant TR was often neglected. However, TR influences the outcome of patients. The aim of this study was to investigate the efficacy and safety of percutaneous balloon mitral valvuloplasty (PBMV) procedure in rheumatic heart disease patients with mitral valve (MV) stenosis and tricuspid valve regurgitation.

METHODSTwo hundred and twenty patients were enrolled in this study due to rheumatic heart disease with MS combined with TR. Mitral balloon catheter made in China was used to expand MV. The following parameters were measured before and after PBMV: MV area (MVA), TR area (TRA), atrial pressure and diameter, and pulmonary artery pressure (PAP). The patients were followed for 6 months to 9 years.

RESULTSAfter PBMV, the MVAs increased significantly (1.7 ± 0.3 cm 2 vs. 0.9 ± 0.3 cm 2 , P < 0.01); TRA significantly decreased (6.3 ± 1.7 cm 2 vs. 14.2 ± 6.5 cm 2 , P < 0.01), right atrial area (RAA) decreased significantly (21.5 ± 4.5 cm 2 vs. 25.4 ± 4.3 cm 2 , P < 0.05), TRA/RAA (%) decreased significantly (29.3 ± 3.2% vs. 44.2 ± 3.6%, P < 0.01). TR velocity (TRV) and TR continue time (TRT) as well as TRV × TRT decreased significantly (183.4 ± 9.4 cm/s vs. 254.5 ± 10.7 cm/s, P < 0.01; 185.7 ± 13.6 ms vs. 238.6 ± 11.3 ms, P < 0.01; 34.2 ± 5.6 cm vs. 60.7 ± 8.5 cm, P < 0.01, respectively). The postoperative left atrial diameter (LAD) significantly reduced (41.3 ± 6.2 mm vs. 49.8 ± 6.8 mm, P < 0.01) and the postoperative right atrial diameter (RAD) significantly reduced (28.7 ± 5.6 mm vs. 46.5 ± 6.3 mm, P < 0.01); the postoperative left atrium pressure significantly reduced (15.6 ± 6.1 mmHg vs. 26.5 ± 6.6 mmHg, P < 0.01), the postoperative right atrial pressure decreased significantly (13.2 ± 2.4 mmHg vs. 18.5 ± 4.3 mmHg, P < 0.01). The pulmonary arterial pressure decreased significantly after PBMV (48.2 ± 10.3 mmHg vs. 60.6 ± 15.5 mmHg, P < 0.01). The symptom of chest tightness and short of breath obviously alleviated. All cases followed-up for 6 months to 9 years (average 75 ± 32 months), 2 patients with severe regurgitation died (1 case of massive cerebral infarction, and 1 case of heart failure after 6 years and 8 years, respectively), 2 cases lost access. At the end of follow-up, MVA has been reduced compared with the postoperative (1.4 ± 0.4 cm 2 vs. 1.7 ± 0.3 cm 2 , P < 0.05); LAD slightly increased compared with the postoperative (45.2 ± 5.7 mm vs. 41.4 ± 6.3 mm, P < 0.05), RAD slightly also increased compared with the postoperative (36.1 ± 6.3 mm vs. 28.6 ± 5.5 mm, P < 0.05), but did not recover to the preoperative level. TRA slightly increased compared with the postoperative, but the difference was not statistically significant (P > 0.05). The PAP and left ventricular ejection fraction appeared no statistical difference compared with the postoperative (P > 0.05), the remaining patients without serious complications.

CONCLUSIONSPBMV is a safe and effective procedure for MS combined with TR in patients of rheumatic heart disease. It can alleviate the symptoms and reduce the size of TR. It can also improve the quality-of-life and prognosis. Its recent and mid-term efficacy is certain. While its long-term efficacy remains to be observed.

Adult ; Aged ; Balloon Valvuloplasty ; methods ; Echocardiography ; Female ; Humans ; Male ; Middle Aged ; Mitral Valve Stenosis ; diagnostic imaging ; therapy ; Rheumatic Heart Disease ; diagnostic imaging ; therapy ; Tricuspid Valve Insufficiency ; diagnostic imaging ; therapy